What are the usual adverse or side effects of hemodialysis in typical adult patients with end‑stage renal disease?

Common Adverse Effects and Complications of Hemodialysis

Hemodialysis causes frequent intradialytic complications in approximately 40% of treatment sessions, with hypotension being the most common acute complication, occurring in nearly 8% of sessions, followed by muscle cramps, hypertensive crisis, and prolonged post-dialysis recovery time that affects quality of life in the majority of patients. 1, 2

Acute Intradialytic Complications

Hypotension (Most Common)

• Intradialytic hypotension (IDH) occurs when systolic blood pressure drops below 90 mmHg or declines more than 30 mmHg during treatment 3
• Affects approximately 25% of dialysis sessions and is the single most frequent acute complication 2
• Caused primarily by aggressive ultrafiltration in response to interdialytic weight gain 3
• Can lead to myocardial stunning, cardiac arrhythmias, and is independently associated with increased mortality risk 3
• Diabetic patients and those with ultrafiltration rates exceeding 1000 mL/hour face significantly higher risk 2

Muscle Cramps

• Occur in approximately 22% of hemodialysis sessions 2
• More common in patients with rapid ultrafiltration (>1000 mL/hour) and those with diabetes 2
• Associated with longer duration on dialysis 2

Hypertensive Crisis

• Develops in approximately 14% of dialysis sessions 2
• Represents paradoxical blood pressure elevation during or immediately after treatment 2

Other Acute Complications

• Pruritus (itching) affects 10% of sessions 2
• Fever occurs in 7% of sessions 2
• Disequilibrium syndrome (more common in patients with shorter dialysis duration) 2
• Bleeding complications (64% involve vascular access sites) 2

Post-Dialysis Recovery Issues

Prolonged Recovery Time

• Recovery time extends 2-6 hours for 41% of hemodialysis patients and exceeds 6 hours for 27% 3
• Recovery time shows linear association with increased risks for death and hospitalization 3
• Patients identify feeling "washed out or drained" as more important than death or hospitalization when rating treatment burden 3

Vascular Access Complications

Access-Related Problems

• Vascular access issues represent a major source of morbidity throughout the course of hemodialysis treatment 1, 4
• Central venous catheters carry the highest infection risk among access types 4
• Arteriovenous fistulas require several months to mature before use 4
• Arteriovenous grafts can be used within 24 hours but have intermediate infection risk 4
• Bleeding from vascular access sites accounts for 64% of all bleeding complications 2

Cardiovascular Complications

Long-Term Cardiac Effects

• Cardiovascular disease is the most common comorbid condition and leading cause of early mortality in hemodialysis patients 1
• Intradialytic blood pressure variability contributes to myocardial stunning 3
• Annual mortality ranges from 17-20% in the United States for patients on hemodialysis, with 3-year and 5-year survival rates of only 55% and 40% respectively 5

Metabolic and Systemic Complications

Hypoglycemia Risk (Especially in Diabetics)

• Hemodialysis commonly precipitates hypoglycemic episodes requiring adjustment or discontinuation of insulin and oral antihyperglycemic agents 6
• Multiple mechanisms contribute: decreased gluconeogenesis, impaired insulin clearance, reduced insulin degradation from uremia, increased erythrocyte glucose uptake during dialysis, and impaired counterregulatory hormone responses 6

Dialyzer Membrane Reactions

• Reactions to dialyzer membrane materials occur as treatment-related side effects 1

Pleural Effusions

• Pleural effusions occur in approximately 21-25% of hospitalized hemodialysis patients 7
• Fluid overload accounts for 61.5% of cases, while cardiac impairment causes 46% 7

Special Population Considerations

Diabetic Patients

• Diabetic patients with ESRD experience the worst adjusted-survival rates among the dialysis population 6
• Face multisystem problems including higher rates of limb amputation 8
• Experience vascular access complications more frequently 8

Intensive Hemodialysis Modifications

• Short daily hemodialysis reduces per-session probability of intradialytic hypotension by 20%, while nocturnal schedules reduce it by 68% compared to conventional thrice-weekly treatment 3
• Intensive hemodialysis carries possible increased risk of vascular access procedures 7
• May cause accelerated decline in residual kidney function 7
• Can increase caregiver burden for home-based intensive regimens 7

Critical Safety Concerns

Fatal Complications

• Four deaths per 1000 dialysis sessions have been documented in under-resourced settings, with three from bleeding and one from disequilibrium syndrome 2
• Fatal complications occur predominantly during understaffed nighttime shifts 2
• Nearly half of dialysis sessions in resource-limited settings are associated with acute complications, some of which are fatal 2

Common Clinical Pitfalls

• Do not rely on pre-dialysis or post-dialysis blood pressure measurements alone for hypertension management, as intradialytic blood pressure variability is the critical factor 5
• Recognize that complications occur most frequently during understaffed periods, particularly nighttime shifts 2
• Avoid aggressive ultrafiltration rates exceeding 1000 mL/hour when possible, as this dramatically increases hypotension and cramping risk 2
• Monitor diabetic patients more intensively for hypoglycemia during and after dialysis sessions 6